A nurse in the emergency room is assessing a patient who was brought in following a seizure. The nurse suspects the patient may have bacterial meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Assess the cranial nerves.

Decrease environmental stimuli.

Close the room.

Administer an antipyretic.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing the cranial nerves is important, but it is not the immediate next step after implementing droplet precautions for suspected bacterial meningitis.

Choice B reason: Decreasing environmental stimuli can help reduce the risk of seizures and is a supportive measure for a patient with suspected bacterial meningitis.

Choice C reason: Closing the room is part of implementing droplet precautions but is not an action that needs to be initiated by the nurse as it should already be in place.

Choice D reason: Administering an antipyretic may be necessary if the patient has a fever, but it is not the immediate next action after droplet precautions.

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Correct Answer is A

Explanation

Choice A reason: Right lower quadrant.
McBurney's point is located in the right lower quadrant of the abdomen, which is one-third of the distance from the anterior superior iliac spine to the umbilicus. This is the area where tenderness is most likely to be maximal in cases of acute appendicitis.

Choice B reason: Left lower quadrant
The left lower quadrant is not typically associated with appendicitis pain, as the appendix is located in the right lower quadrant of the abdomen.

Choice C reason: Right upper quadrant
The right upper quadrant is generally associated with other conditions such as gallbladder issues, not appendicitis.

Choice D reason: The left upper quadrant
The left upper quadrant is also not associated with appendicitis pain, as it is on the opposite side of the typical location of the appendix.

A. The test measures the hormone that attaches to a protein in your blood. B. The test measures the hormone that feeds the thyroid gland. C. The test measures the hormone that indicates the metabolic rate. D. The test measures the hormone that controls energy levels.

Correct Answer is C

Explanation

Choice A reason: The statement is incorrect because TSH does not attach to a protein in the blood; it stimulates the thyroid gland to produce thyroid hormones.

Choice B reason: This choice is partially correct. TSH does stimulate the thyroid gland, but the main purpose of the test is not to measure the 'feeding' of the gland but to assess its function and how well it's producing thyroid hormones.

Choice C reason: This is the correct statement. TSH levels are measured to determine the thyroid gland's activity, which directly influences the metabolic rate. The normal range for TSH levels in adults is typically 0.4 to 4.0 milliunits per liter (mU/L). However, these values can vary slightly based on the laboratory and the age of the individual.

Choice D reason: While TSH does influence energy levels by regulating thyroid hormone production, this choice does not directly explain the purpose of measuring TSH levels.

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point.

Correct Answer is A

Explanation

A nurse is talking with a client whose thyroid stimulating hormone (TSH) level will be measured. Which of the following statements by the nurse explains the purpose of this test?

Correct Answer is C

Explanation

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client’s affected arm?

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

A nurse is caring for a patient who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the patient is effectively responding to treatment?

A nurse is assessing a client who reports ear pain for the past three days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions?

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?

A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test (RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result?

A nurse is assessing a client 15 minutes after administering 2 mg of morphine sulfate via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

A nurse is assessing a client who is 24 hours postoperative following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of fat embolism syndrome (FES)?